$ |
product A least expensive |
$$ |
product B more expensive than A |
$$$ |
product C more expensive than B |
$$$$ |
product D more expensive than C |
$$$$$ |
product E more expensive than D |
!!!!! |
product F is substantially more expensive than A-E |
Non-Formulary |
product G not part of the formulary |
MAC |
Maximum Allowable Cost - the maximum charge that will be paid for the product whether generic or brand. |
Drug Name (Generic Name) |
The BRAND NAME of the drug followed by generic in parentheses or the generic name only. |
Drug and/or Generic Comments |
Comments such as: (suspension only), (caps, tabs only), (tablets non-form), etc. |
Strength and/or Dosage |
The dosage of a drug covered if not all strengths are formulary as in half-strength program. |
Strength and/or Dosage Comments |
Comments related to dosage/quantity limitations. |
|
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| Prev. Page | Prev. Class | Next Class | Next Page |
TOPICAL DERMATOLOGICAL DRUGS
Relative Cost |
MAC |
Drug Name (Generic Name) Drug and/or Generic Comments |
Strength and/or Dosage Strength and/or Dosage Comments |
|
|
DIAB (emollient) |
|
|
|
fluorouracil (fluorouracil) |
|
$ |
|
ammonium lactate (lactate, ammonium) |
cream |
$ |
|
benzoin (benzoin) |
|
$ |
|
DRYSOL (aluminum chloride hexahydrate) |
|
$ |
|
hypercare (aluminum chloride hexahydrate) |
|
$ |
|
silver nitrate (silver nitrate) |
|
$ |
|
SILVER NITRATE APPLICATOR (silver nitrate) |
ea |
$ |
|
silver nitrate applicator (silver nitrate) |
ea |
$ |
|
XERAC AC (aluminum chloride hexahydrate) |
|
$$ |
|
hydroquinone (hydroquinone) |
4 % cream |
$$ |
|
hydroquinone (kera1/oxbn/avobnz/o-crl/h-qui) |
4 % cream |
$$ |
|
hydroquinone (oxyben/pdo/oct cin/h-quinone) |
cream |
$$ |
|
hydroquinone (paba/oxyben/dioxyb/hydroquinon) |
4 % cream |
$$ |
|
hydroquinone (paba/oxyben/dioxyb/hydroquinon) |
gel |
$$ |
|
melpaque hp (hydroquinone/sunscreens) |
|
$$ |
|
melquin hp (hydroquinone) |
|
$$ |
|
nuquin hp (hydroquinone/sunscreens) |
|
$$ |
|
nuquin hp (paba/oxyben/dioxyb/hydroquinon) |
|
$$ |
|
RADIAGEL (emollient) |
|
$$$ |
|
ALPHAQUIN HP (hydroquinone/sunscreens) |
|
$$$ |
|
ELDOPAQUE FORTE (hydroquinone/sunscreens) |
|
$$$ |
|
GLYQUIN (oxyben/pdo/oct cin/h-quinone) |
|
$$$ |
|
obagi nu-derm (hydroquinone) |
4 % cream |
$$$ |
|
OBAGI NU-DERM (hydroquinone/sunscreens) |
4 % cream |
$$$ |
|
SOLAQUIN FORTE (paba/oxyben/dioxyb/hydroquinon) |
|
$$$$ |
|
ELDOQUIN FORTE (hydroquinone) |
|
$$$$ |
|
GLYQUIN XM (kera1/oxbn/avobnz/o-crl/h-qui) |
|
$$$$ |
|
IODOSORB (cadexomer iodine) |
|
$$$$$ |
|
ACLARO (avobenz/octinox/h-quinone) |
|
$$$$$ |
|
ACLARO PD (avobenz/octinox/h-quinone) |
|
$$$$$ |
|
ALDARA (imiquimod) |
|
$$$$$ |
|
CARAC (fluorouracil) |
|
$$$$$ |
|
EFUDEX (fluorouracil) |
|
$$$$$ |
|
ELIDEL (covered if prescribed by dermatologist) (pimecrolimus) |
|
$$$$$ |
|
FLUOROPLEX (fluorouracil) |
|
$$$$$ |
|
LUSTRA (hydroquinone) |
|
$$$$$ |
|
LUSTRA-AF (hydroquinone/sunscreens) |
|
$$$$$ |
|
LUSTRA-ULTRA (hydroquinone) |
|
$$$$$ |
|
OXSORALEN (methoxsalen) |
|
$$$$$ |
|
PROTOPIC (Covered if prescribed by dermatologist) (tacrolimus) |
|
Non-Formulary |
|
ACCUZYME |
|
Non-Formulary |
|
ALLANDERM-T |
|
Non-Formulary |
|
ALLANENZYME |
|
Non-Formulary |
|
ALLANFILLENZYME |
|
Non-Formulary |
|
AMMONIUM LACTATE |
|
Non-Formulary |
|
ANANA FORTE |
|
Non-Formulary |
|
ATOPICLAIR |
|
Non-Formulary |
|
AVAGE |
|
Non-Formulary |
|
BENOQUIN |
|
Non-Formulary |
|
BIAFINE |
|
Non-Formulary |
|
BIONECT |
|
Non-Formulary |
|
CARMOL 40 |
|
Non-Formulary |
|
CEROVEL |
|
Non-Formulary |
|
ELETONE |
|
Non-Formulary |
|
EPICERAM |
|
Non-Formulary |
|
EPIQUIN MICRO |
|
Non-Formulary |
|
GLADASE |
|
Non-Formulary |
|
GLADASE-C |
|
Non-Formulary |
|
GORDO-UREA |
|
Non-Formulary |
|
GRANUL-DERM |
|
Non-Formulary |
|
GRANULEX |
|
Non-Formulary |
|
HYDRO 40 |
|
Non-Formulary |
|
HYDROQUINONE |
|
Non-Formulary |
|
HYLIRA |
|
Non-Formulary |
|
HYLIRA |
|
Non-Formulary |
|
IODOFLEX |
|
Non-Formulary |
|
KERAFOAM |
|
Non-Formulary |
|
KERALAC |
|
Non-Formulary |
|
KERATOL 40 |
|
Non-Formulary |
|
KERATOL PLUS |
|
Non-Formulary |
|
KEROL |
|
Non-Formulary |
|
KEROL |
|
Non-Formulary |
|
KEROL |
|
Non-Formulary |
|
KEROL ZX |
|
Non-Formulary |
|
KOVIA 6.5 |
|
Non-Formulary |
|
KOVIA OINTMENT |
|
Non-Formulary |
|
LAC-HYDRIN (12%) |
|
Non-Formulary |
|
LACLOTION |
|
Non-Formulary |
|
LACTIC ACID |
|
Non-Formulary |
|
LACTIC ACID |
|
Non-Formulary |
|
LACTINOL |
|
Non-Formulary |
|
LACTINOL-E |
|
Non-Formulary |
|
LATRIX |
|
Non-Formulary |
|
LEVULAN |
|
Non-Formulary |
|
MELANEX |
|
Non-Formulary |
|
MELQUIN-3 |
|
Non-Formulary |
|
MIMYX |
|
Non-Formulary |
|
OPTASE |
|
Non-Formulary |
|
OXALIS |
|
Non-Formulary |
|
PANAFIL |
|
Non-Formulary |
|
PANRETIN |
|
Non-Formulary |
|
PAPTASE |
|
Non-Formulary |
|
PRUDOXIN |
|
Non-Formulary |
|
RADIAPLEXRX |
|
Non-Formulary |
|
RADIGEL |
|
Non-Formulary |
|
RE UREA 40 |
|
Non-Formulary |
|
REGRANEX |
|
Non-Formulary |
|
REMERGENT HQ |
|
Non-Formulary |
|
RENOVA |
|
Non-Formulary |
|
REVINA |
|
Non-Formulary |
|
RINNOVI |
|
Non-Formulary |
|
SANTYL |
|
Non-Formulary |
|
SODIUM HYALURONATE |
|
Non-Formulary |
|
SOLAGE |
|
Non-Formulary |
|
SOLARAZE |
|
Non-Formulary |
|
TBC |
|
Non-Formulary |
|
TETRIX |
|
Non-Formulary |
|
TRETINOIN |
|
Non-Formulary |
|
TRI-LUMA |
|
Non-Formulary |
|
TRYPSIN |
|
Non-Formulary |
|
U-KERA E UREA EMOLLIENT |
|
Non-Formulary |
|
UMECTA |
|
Non-Formulary |
|
UMECTA PD |
|
Non-Formulary |
|
UREA |
|
Non-Formulary |
|
UREA |
|
Non-Formulary |
|
UREA-C40 |
|
Non-Formulary |
|
UREALAC |
|
Non-Formulary |
|
UREALAC |
|
Non-Formulary |
|
VANIQA |
|
Non-Formulary |
|
VEREGEN |
|
Non-Formulary |
|
X-VIATE |
|
Non-Formulary |
|
XCLAIR |
|
Non-Formulary |
|
XENADERM |
|
Non-Formulary |
|
ZIOX |
|
Non-Formulary |
|
ZIOX 405 |
|
Non-Formulary |
|
ZONALON |
|
Formulary Date: 10/07/2008 Update Date: 10/09/2008 V1.3.0